EXTRACORPOREAL LIFE SUPPORT FOR PROLONGED CARDIAC ARREST Massimo MASSETTI Cardiac Surgery Department University of Sacred Heart, Gemelli Hospital Rome «No financial interest to declare» ESC CONGRESS 2012
ANNUAL SUDDEN CARDIAC ARREST EVENTS 350,000 USA 750,000 Europe 50,000 Italy 75% out-of-hospital 20% without prior symptoms < 5% survive 95% die without treatment
Refractory Cardiac Arrest Failure to obtain ROSC after at least 30 min of ACLS in normothermia This definition is used to stop resuscitation in a hopeless survival situation: Failure of ROSC Failure to obtain a satisfactory cerebral activity in these conditions ILCOR, AHA, ERC 2005
Critical Early Minutes of CA 100 Survival Rate (percent) 80 60 40 Survival reduced by about 10% each minute defibrillation delayed 20 0 5 10 15 20 25 Time to Defibrillation (minutes)
Arrest Time: Pathophysiology Cerebral blood flow achieved with CPR is inversely proportional to arrest time CPR started in 2 minutes - CBF to 50% normal CPR after 5 minutes - CBF 28% normal CPR after 10 minutes - CBF = 0%
Post-Ischemic Encephalopathy After ROSC is achieved Immediate post-ca no-reflow phenomenon (blood sludging) Delayed protracted cerebral hypoperfusion (vasospasm) Multifocal inhomogeneous cerebral hypoperfusion Resuscitation 1992;23:1-20 Stroke 1992;23:45-53 Circulation 1995;92:2572-8
Conventional Approach
CLINICAL FINDINGS Cardiac Arrest NO Flow Cardiac Massage LOW Flow
-Interrupt injurios process; RESUSCITATION -Restoring cardiopulm. and cerebral function; -Mitigate reperfusion injury RESUSCITATION 2012 -Increasing ROSC (Minimally interrupted CPR, Hands-on Defibrillation, Epinefrine ) -Supported Circulation (ECPR) -Cerebral Protection (Intra-Arrest Cooling, Therapeutical Hypothermia)
RESUSCITATIVE E.C.L.S. E.C.P.R. -1992: First used in children for rescue therapy; -improved survival with refractory cardiac arrest - Long arrest times (>95min) in children; -Mid-late 1990s: Investigations in adults
Survival rate 20% >50% brain Death
E-CPR TRIALS -2003, Chen et al. -57 pts with a variety of resuscitation times; -Overall Survival rate 31,6 (18 of 57); -One survivor of three (CPR>60 min) had severe neurological deficit; -Survivors shorter duration of CPR; -96,5% survivors had witnessed arrest; -100% survival with CPR < 30 min
51 patients (42 + 15 years) No flow: 3 [1-7] min Low flow: 120 [102-149] min ECLS failed in 9 (18%) patients Strong correlation with: Serum lactates > 16,3 mmol/l Low flow time > 100 min Time to ECLS Survival: 2 (4%) avec GOS 4 and 5 Death: MOF (47%), BD (20%), HS (14%)
IN HOSPITAL CARDIAC ARREST 38 patients 30 day survival 13 (34%) 1 year survival 10 (26%) Witnessed CA 35 (92%) Bystander CPR 35 (92%) Time to ECMO 25 min Therap. Hypot. 4 (11%) ECMO hours 9 (5-62) Hospital Stay d 18 (2-34) Out of HOSPITAL CARDIAC ARREST 39 patients 30 day survival 5 (13%) 1 year survival 5 (13%) Witnessed CA 32 (82%) Bystander CPR 28 (72%) Time to ECMO 59 min Therap. Hypot. 21 (54%) ECMO hours 10 (3-40) Hospital Stay d 22 (1-42)
The outcomes of patients treated with ECLS were better for IHCA than OHCA, but the difference in outcomes disappeared after adjusting for patient factors and time delay in starting ECLS
E-CPR: Key-Points -Multiple studies, mostly retrospective analysis; -varying results, but promising approach; -Criteria for success: a) No-flow time close to 0 min b) Bystanders CPR c) Short low-flow time to ECMO initiation d) Brain Protection Strategy (Hypothermia)
The key to improving outcome in patients who have suffered cardiac arrest is achieving early return to supported circulation with BRAIN protective strategy.
RESUSCITATION PROGRAM Multidisciplinary C.A. Network with TEAM APPROACH Restore Perfusion -Early CPR by EMS; -Continuous ECM -Rapid ECLS Institution Brain Protection -intra-arrest Cooling - Therapeutical Hypotermia and remove the Cardiac Arrest causes
Automatic ECM
Time to do exams Mobility and Transport of patients
Resuscitative Hypothermia Fever Accelerates Injury Hypothermia Preserves Tissue 41 40 39 38 37 37 36 35 34 33º 32º
Witnessed CA Castren et al. Circulation 2010 IA cooling (96) vs control (104)
Out-Hospital Cardiac Arrest ROSC Rapid core Cooling 25 ml/kg No ROSC Therapeutic Hypothermia
FRENCH ALGORITHM